星空入口

Find out when 鈥榓nd鈥� means 鈥榦r鈥� in diagnosis coding.

Broken bones are one of the most common injuries that radiology coders encounter in their workflows. The ICD-10-CM code set makes it easy to locate several fracture codes based on which body structure is injured, but you鈥檒l occasionally receive a report that lists a perplexing diagnosis.

Check out the medical report listed below and learn which codes apply to this unique situation.

Analyze This Ankle Fracture Report

Location: Urgent care facility

HPI: Patient presents with right lateral ankle pain after rolling ankle while walking 鈥渇eeling and hearing a pop.鈥� States they are unable to bear weight on the ankle. Denies distal paresthesia. States that they have taken ibuprofen prior to arrival at urgent care today. Denies other acute problems or concerns.

Physical Exam: Right ankle: Swelling laterally. No deformity, ecchymosis, or erythema. Tenderness to palpation of the distal fibula. No crepitus to palpation or range of motion. Decreased range of motion of both dorsi and plantarflexion secondary to pain. Thompson鈥檚 test negative. No deformity to the Achilles tendon to inspection or palpation. No tenderness to palpation of the bony or soft tissues of the right foot. CMS intact distally right lower extremity.

Procedure: Lateral, anteroposterior (AP), and mortise X-ray views.

Description: Patient presents with right lateral ankle pain after rolling ankle while walking 鈥渇eeling and hearing a pop.鈥� States that they are unable to bear weight on the ankle.

Right ankle X-ray obtained and is significant for spiral fracture distal fibula on interpretation. Radiology report available prior to discharge notes mildly displaced spiral fracture of the distal fibula. Patient informed of these findings.

Discharged with diagnosis of closed fracture of the distal end of left fibula.

A short leg posterior splint applied to the right lower extremity. Circulation, movement, and sensation (CMS) checked both before and after application and found to be intact. Provided crutches and crutch training. Emphasized no weightbearing until cleared by orthopedics. Symptomatic measures reviewed. Follow-up with orthopedics initiated. Advised to seek medical attention sooner than upcoming appointment if symptoms worsen.

Now that you鈥檝e reviewed the medical documentation, it鈥檚 time to assign the correct procedure and diagnosis codes.

Recognize Your Radiology Code Options

The CPT^庐 code set includes two codes for ankle X-rays:

• 73600 (Radiologic examination, ankle; 2 views)
• 73610 (Radiologic examination, ankle; complete, minimum of 3 views)

Documentation indicates the urgent care facility captured three X-rays of the patient鈥檚 ankle. The views include lateral, AP, and mortise. Code 73600 covers only two views, and it is incorrect to assign that for a procedure consisting of three or more views, since 73610 exists.

You鈥檒l assign 73610 to report the X-rays captured and the interpretation of the images.

Sift Through the Fracture Diagnosis Codes

After reviewing the X-rays and performing a physical examination, the physician diagnosed the patient with a closed fracture of the distal end of left fibula. Turn to the ICD-10-CM Alphabetic Index and locate the condition by following Fracture, traumatic > fibula > lower end > specified NEC, where you鈥檒l find S82.83- (Other fracture of upper and lower end of fibula). You鈥檒l then turn to the Tabular List to verify the code.

The S82.83- subcategory requires a 6^th character to specify the laterality, which in this case is 鈥�2鈥� to indicate the injury occurred on the left leg. Next, the ICD-10-CM code set instructs you to assign a corresponding 7^th character to complete the code. The 7^th character explains the stage of treatment for the patient鈥檚 injury. Since the physician diagnosed the patient with a closed fracture and the patient is seeking active treatment for the injury, you鈥檒l append 鈥淎鈥� as the 7^th character.

Your claim will include S82.832A (Other fracture of upper and lower end of left fibula, initial encounter for closed fracture) as the diagnosis code for the encounter. Also, you may notice the code descriptor lists 鈥渇racture of upper and lower end of the left fibula,鈥� and the physician made a definitive diagnosis of a fracture of the fibula鈥檚 lower end. The term 鈥渁nd鈥� includes both anatomical sites or either of them.

Why? According to the ICD-10-CM Official Guidelines, section I.A.14, 鈥淭he word 鈥榓nd鈥� should be interpreted to mean either 鈥榓nd鈥� or 鈥榦r鈥� when it appears in a title.鈥� This means that S82.832A will be assigned for a fracture of the upper end of the left fibula, a fracture of the lower end of the left fibula, or fractures to the upper and lower ends of the left fibula.

Wrap Up Your Claim

For this case, you鈥檒l assign the following codes:

CPT^庐: 73610

ICD-10-CM: S82.832A.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC